November 27, 2015 scene outside a Colorado Springs Planned Parenthood clinic, where an anti-abortion terrorist killed three people and injured nine

Last Wednesday, March 1, House Republicans stepped up their witch-hunt against supporters of women’s right to abortion. The so-called “Select Investigative Panel on Infant Lives,” the House committee established to investigate the alleged selling of fetal tissue by Planned Parenthood, began its deliberations on that date. The committee Chair, Rep. Marsha Blackburn (Tennessee), spearheaded the congressional attempt to defund Planned Parenthood in the wake of the national brouhaha spawned by a series of videos that claimed to show how the women’s health organization profited from selling fetal tissue.

The hearings proceeded despite the fact that the videos were discredited, owing to their highly edited content. (The videographers were indicted in Texas for tampering with government evidence and other crimes.) Moreover, some 30 states investigated the claims made in the videos and each found Planned Parenthood had never participated in such activity. Blackburn’s committee is focusing on the use fetal tissue in scientific research, which has been legal in the United States since the 1970s.

Why continue investigating a nonexistent crime? Because the House committee’s real purpose is to spread the lies of anti-abortion activists and lay the groundwork for further attacks on women’s rights. In another deadly move, Blackburn subpoenaed scientists involved in medical research using fetal tissue and staff at a New Mexico abortion clinic, demanding that the organizations subpoenaed divulge the names of personnel and volunteers. By demanding these names and making them public, Blackburn and her colleagues will create a hit-list for anti-abortion terrorists like those who murdered Dr. George Tiller in his church in 2009 or the more recent murder of three people in a Colorado Springs Planned Parenthood clinic.

Pro-choice demonstrators protested outside the U.S. Supreme Court last week as it began its deliberations on a Texas abortion case. More social action is needed by supporters of a woman’s right to choose abortion if we are to beat back the mounting attacks on this legal medical service. Safe abortion care should be available and accessible to all who desire it.

New guidelines from the USPSTFrecommend that all pregnant women and new mothers be screened for depression. Fantastic! This recommendation is a big win for women and public health. Women who suffer from postpartum depression often are slammed unexpectedly with this ailment without any knowledge about this maternally associated illness.

However, the insurance industry is poised to slam these women with another blow; this time, to their pocketbooks. According to the New York Times, life and disability insurers have penalized women with postpartum depression by charging them more money, excluding mental illness from coverage, or denying them any coverage at all.

Have I said before that I hate insurance companies? We need to nationalize them and use the revenue to finance a national health system where healthcare is a right, not a privilege.

And that’s exactly what it is. This most recent attack is part of a campaign of violence and intimidation against the patients and providers of abortion services. This intimidation is not the work of lone gunmen with mental health issues; rather, it extends to state governments, which have instituted laws aimed at closing Planned Parenthood and other women’s health clinics that provide abortion services, and to many of the presidential hopefuls in the current race for U.S. President.

Since 1993, according to a January 2015 report by the the National Abortion and Reproductive Rights Action League (NARAL), eight abortion clinic workers – including four doctors, two clinic employees, a clinic escort, and a security guard – have been murdered in the United States. Yesterday’s terror attack in Colorado Springs, brings the death toll to 11. Seventeen attempted murders have also occurred since 1991. Anti-choice terrorists have directed more than 6,800 reported acts of violence against abortion providers since 1977, including bombings, arsons, death threats, bioterrorism threats, and assaults, as well as more than 188,000 reported acts of disruption, including bomb threats, hate mail, and harassing calls.

Healthcare providers should support women’s right to choose abortion. A woman’s right to an abortion — a legal procedure in the United States — is under attack. All those who support a woman’s right to control her own body need to speak out against this campaign of violence and intimidation.

Millions of poor, working-class people in the United States remain without health insurance, despite passage of the Affordable Care Act (ACA) in 2010. Those without health insurance tend to be in the South, and they’re poor. The third wave of enrollment in the ACA program is currently underway.

Under the ACA’s health insurance reform, millions of uninsured Americans obtained health insurance. Poor uninsured obtained Medicaid in those states that agreed to expand the Medicaid rolls. Millions of other people obtained insurance on the federal and state health insurance exchanges.

The ACA allowed millions of uninsured people to get health insurance. As I’ve pointed out before, (See my August 8, 2015 post) this reform has been a boondoggle for the insurance industry while not providing adequate insurance for the newly insured.

Not content with the billions they’ve received already, the insurance magnates are preparing to gouge the newly insured with even steeper premiums. In Tennessee, the state is allowing insurers to raised premiums by up to 36 percent; in Iowa, the state is allowing up to a 29% hike. In addition to high premiums, the insurance plans being offered on the health insurance exchanges also have astronomically high deductibles. Insurance plans with $5,000 deductibles really mean that those covered don’t have insurance, as they will defer services so as not to incur bills.

Insurance companies profit from gambling on the lives of working people! Let’s put an end to this outrage! We need a national healthcare system that provides universal coverage for everyone in the country.

I turned 65 recently, and signed up for Medicare. I’m not planning on retiring anytime soon. However, the occasion got me thinking about what life might be like for me and my family when I do stop working. I’m in really good shape compared to others my age: I’m in a highly compensated profession; I’ve got good health insurance and dental coverage; and I’ve got a generous defined benefits and defined contribution retirement plan.

For the majority of older people in this country, their main source of income after retirement is Social Security, accounting for four out of five dollars received by elderly people with low incomes. (See recent AARP report.) Only a third of U.S. elderly receive pension or retirement savings income.

The inequities of the working years continue after retirement. People 65 and older have an average yearly income of $31,742; however, half of this population has an income of less than $19,604. Because of their higher lifetime earnings, men get higher Social Security benefits than women, and whites get higher benefits than minorities. In fact, minorities are less likely to have any income from Social Security, pensions, or retirement savings plans — let alone interest or dividends.

This income inequality, which is rooted in our social class structure, is a major driver of mortality. Dr. Corey Anderson, a sociologist from the University of Arizona, recently published a book, The End Game: How Inequality Shapes Our Final Years, that studies how income determines who even gets to grow old. A recent report by the National Academy of Sciences shows that not only are those who had higher educational attainment and higher incomes before retiring are living longer than those with less education and income, but the gap is widening.

According to the NAS report, men born in 1930 who reached age 50 had an additional 26.6 years if they were in the lowest income category; whereas they had 31.7 years if they were in the highest income category — a gap of some 5 years. The report projects that men born in 1960 in the lowest income bracket have shown no improvement in life expectancy, while those in the highest income bracket will experience an increased life expectancy of 7 years — increasing the gap to about 12 years.

The poor, working-class, and rural people of this country — especially those of color — die younger. An entire life course marked by low income, poor education, dilapidated housing, unhealthy environments, and inadequate healthcare dooms these populations to unjustly early deaths.

This injustice must stop. However, it won’t end until the social and economic injustice in which it is rooted is ended, as well.

Care providers often struggle with whether a patient should be admitted as an inpatient hospitalization or under an “observation” status. What’s the difference?

According to the Medicare Payment Advisory Commission (MedPac) [page 57]:

“If a Medicare patient does not initially meet the criteria for inpatient admission but the attending physician concludes the patient should be observed in the hospital for a period of time before being sent home, the patient can remain in the hospital in observation status. Observation stays are billed as outpatient services rather than inpatient admissions.”

For the inpatient care team, whether someone should be admitted as an inpatient or under observation rests on the judgment of whether the patient needs hospital treatment or is, in fact, just in need of short-term observation.

Patients admitted for “observation” most often go to a regular inpatient bed, receiving the same level of care as other inpatients. However, Medicare treats the admission as outpatient care, which means the patient picks up a larger share of the costs. In addition, a patient on observation status doesn’t qualify for Medicare coverage of rehab or skilled nursing facility care upon discharge. “Observation,” therefore, isn’t such a great deal for patients.

Turns out, however, that observation status is a good deal for the federal government and hospitals. The U.S. Department of Health and Human Services has touted the drop in hospital readmissions as an improvement in patient safety. However, a large percentage of this drop is attributable merely to a shifting of readmissions to observations, which aren’t counted by Medicare as admissions. Between 2006 and 2013, observation stays increased by 96 percent, accounting for more than half of the apparent decline in total Medicare admissions during that 7-year period (see page 55).

Hospitals are calling increasing numbers of stays “observation.” Following a wave of disallowed payments to hospitals for brief inpatient admissions, hospitals began increasing observation stays. Although such observation stays pay less than an inpatient admission, less payment is preferred over no payment at all!

Moreover, Medicare instituted new penalties for readmissions, which also incents hospitals to shift patients returning within 30 days of a prior discharge to observation status. Remember, a patient stay under “observation” is outpatient care, not an inpatient hospitalization, and, means the hospital avoids a penalty for readmission on such a patient.

According to the Centers for Medicare and Medicaid Services (CMS), about 10 percent of all hospital stays occurring within 30 days of discharge are now classified as “observation.” A quarter of hospitals classified 14.3 percent or more of all repeat stays as “observation,” and between 2010 and 2013, 36 percent of the claimed decrease in readmissions was actually just a shift to observation stays.

So, the hoopla around the decline in hospital readmissions may be overblown. Hospitals are meeting Medicare metrics for quality (and avoiding fines) with some improvement in care — and some gaming.

Racial inequality in economic, social, and health terms is rampant across the United States. African Americans suffer from twice the level of unemployment attributed to whites. Poverty is twice as prevalent among African Americans as among whites. When we find employment, African Americans, on average, make 62 cents for every dollar earned by whites. African Americans have twice the incidence of and mortality from stroke, diabetes, kidney disease, and many cancers. We get sick early in life, suffer more morbidity, and die at a younger age. This bleak picture for African Americans is true nationally.

That being said, some states are worse than others. Some would think, immediately, that the worse states are in the South. Here, we ought to remember Malcolm X’s observation that “Down South is anywhere south of the Canadian border.” In a recent examination of conditions for African Americans in all the states in the Union, the newsletter 24/7 Wall St. found these states to be the worst:

1. Wisconsin

2. Minnesota

3. Rhode Island

4. Illinois

5. Pennsylvania

6. Michigan

7. Connecticut

8. New Jersey

9. Kansas

10. Arkansas

Turns out none of these states are in the South. What they tend to have in common is widespread racial residential segregation. As I’ve pointed out in the past, residential segregation is still as prevalent in this country as it was in the 1950s and 60s. Six of the 10 states in 24/7 Wall St’s list are home to almost half of the 30 most segregated cities in the U.S., according to a University of Michigan study on racial segregation. Residential segregation results in the herding of African Americans into areas with few jobs. These ghettoes are systematically denied adequate investment in housing, schools. good food sources, and most other services.

These social and economic inequities are what underlies the racial health inequities. To address racial health disparities, we must deal with the social inequities that spawn them. New York City Health Commissioner, Mary Bassett, agrees. In a recent interview with Politico, she explained that racist discrimination is an important social determinant of health. “Neighborhoods that are disadvantaged need [to] correct a historic injustice,” Bassett said to Politico. “The framing matters.”

Yes, the historic injustice of racial discrimination must be corrected in order to improve the health and well being of African Americans.

The Affordable Care Act, passed into law in 2010, expanded health insurance coverage through establishing health insurance exchanges and establishing a mechanism for states to expand Medicaid eligibility. As I’ve noted before (see http://tinyurl.com/79gu6ef and http://tinyurl.com/qhl69ao), this law was a boondoggle for the insurance industry, netting these businesses billions in extra profit.

Unfortunately, having an insurance card doesn’t mean you have access to healthcare.

The ACA’s standards for “network adequacy” are so loose that people who now hold health insurance cards obtained through the exchanges find that only a very limited number of physicians and hospitals accept their insurance. This state of affairs adds insult to injury, as people who obtain health insurance through the exchanges are paying exorbitantly high premiums — premiums that the insurance companies threaten to raise if they are forced to include more services in their coverage.

The same problem exists for those with Medicaid. Since passage of the ACA, 27 states have expanded Medicaid eligibility. Most states hire insurance companies or healthcare providers such as hospital systems to manage the clinical care of patients enrolled in their Medicaid plans. Federal regulations require the states to provide adequate access to all services covered. However, the states are allowed to determine what’s “adequate.”

As a result, even the limited federal oversight of health insurance exchanges (itself inadequate to ensure access to care) is lacking with respect to state Medicaid programs. Medicaid patients find themselves with extremely small numbers of physicians willing to care for them, and these patients often must travel long distances in order to find these services.

We need to take profit out of the equation for delivering healthcare services. Let’s get rid of insurance companies who limit services to ensure higher profits. Let’s get rid of the fee-for-service payment system in which physicians limit or refuse to care for Medicaid (or Medicare) patients because the fees are low.

We need a national healthcare system based on universal health insurance coverage. Healthcare is a right, not a privilege.

Joey is one of the regulars at the gym. I try to go to the gym every morning. I’ve been doing so for years, and I’ve actually made a whole cohort of friends like Joey, who go to the gym at the same time as I do. Among them are several other physicians. However, I’m the only one that Joey and several others call “Doc.” Why is that?

It’s because I’m Black. There are very few African-American physicians — less than 7% of the physician workforce. There are even fewer African-American males who are physicians. Joey, who is a European-American, isn’t racist. He’s very explicitly anti-racist. However, implicit racial biases are still held by the majority of whites (and a large minority of African-Americans). (See this New York Times article, or test yourself at Project Implicit.) The biases against and stereotypes of Black men make criminal, delinquent, poor student, and illiterate (among other things) seem fitting; whereas, physician doesn’t quite make sense. Hence, my being a physician becomes my most salient feature. An African-American male physician. Wow!

“Hey, Doc!”

The dearth of African-American physicians in the workforce is an issue that many of us have worked to correct. Now, many are turning their attention to the more particular issue of the scarcity of African-American men in medicine. Marc Nivet, the Chief Diversity Officer for the Association of American Medical Colleges (AAMC), notes in a recent AAMC report that “While the demographics of the nation are rapidly changing and there is a growing appreciation for diversity and inclusion as drivers of excellence in medicine, one major demographic group—black males—has reversed its progress in entering medical school. In 1978, there were 1,410 black male applicants to medical school, and in 2014, there were just 1,337. The number of black male matriculants to medical school over more than 35 years has also not surpassed the 1978 numbers. In 1978, there were 542 black male matriculants, and in 2014, we had 515. No other minority group has experienced such declines.”

The problem begins early. Poor housing, high unemployment, unhealthy environments make African-American children less school-ready. Once in school, they’re thrown into under-resourced educational institutions, which makes them less able to matriculate into college. If lucky enough to get into college, they’re not as prepared for the work and are less likely to go on to graduate work. I’d say the entire educational system is designed to reproduce poor, impoverished working-class African Americans. The U.S. educational system needs a revolutionary overhaul.

In the meanwhile, we can build support networks (mentors, advisors, peer support) for African-American men; we can provide young African-American boys with information; we can, and should, bend the rules and act affirmatively to get African-American men into medicine. Increasing diversity in medicine is imperative. It will bring new ideas, new energy, creativity, and innovation to the profession. And, it’s the right thing to do.

I think a lot of national leaders in family medicine are pondering this very question right now. Just check out the discussion around the future of family medicine in the “Family Medicine for America’s Health” campaign. Here’s the link to a special issu

I believe the U.S. healthcare system is broken. I also believe that, unfortunately, family medicine, as a specialty, is in crisis. To fix the healthcare system, we need integrated, comprehensive, coordinated, high-quality, evidence-based, and safe care provided to all. The payment system for healthcare must be revolutionized to make such care delivery possible. Fee-for-service needs to be abolished. It needs to be replaced by a national health program that provides universal coverage for all. We need clinicians and clinics who not only provide excellent care for the patients who show up in our exam rooms, but that reach out to those who don’t and develop plans for taking care of them, as well. We need clinicians and clinics who also look beyond the healthcare needs of their patient panels and work to improve the health and well being of whole communities.

I firmly believe that providing such care was part of the original vision of family medicine when it was founded as a specialty nearly 50 years ago. The crisis we face is that, after living for two generations in a specialist-dominated, fee-for-service world, our comprehensivist, whole-person perspective has been eroded. We still train family medicine residents to provide comprehensive care; however, market pressure drives them into limited-scope practices. Our residents leave our programs to take on high-paying jobs that do not use much of what we teach in family medicine residency – no inpatient medicine, no call, no pediatric care, no obstetrical care, no gynecologic care, and no procedures. American Academy of Family Physician and American Board of Family Medicine surveys report that about 65% of FPs do not do office gynecology; 50% do no pediatrics; 80% do no office procedures; 60% do no inpatient; and some 93% do no obstetrics.

I’m not arguing that every family physician needs to “do it all.” The breadth of medical knowledge and skill sets needed to provide such comprehensive service is too vast for any one clinician. What I am saying is that a family medicine practice should provide such comprehensive care, which means that their should be clinicians in that practice who provide women’s health services, obstetrics, see children, do procedures, and take care of patients who are hospitalized. Our crisis is that – the way things are going – such practices won’t exist. Moreover, graduates of our residency programs have to replace not only the aging physicians in the community, but they must replace the equally aging population of academic family physicians. Will they teach future generations of family physicians to provide comprehensive care if they, themselves, have chosen not to do so?

Bottom line: Unless there is a dramatic and fundamental shift in the direction that family medicine is headed, I believe it will die as a specialty within the next generation.

Pretty grim statement. However, I do think there’s hope. Current economic realities make the argument for comprehensive primary care more compelling. Employers, state and federal governments, and insurers are reeling from the astronomical and unsustainable costs of health care. I think the time is right for pushing for payment reform in healthcare. Campaigning for payment reform needs to be our number one priority.

So, to answer the question in the headline of this post, here’s my list of critical initiatives family medicine practices should be taking in the next 2-to-5 years to become a lifeline for U.S. healthcare:

Join with others in campaigning for payment reform (pay for comprehensive, coordinated care)

Build team-based, comprehensive practices that provide wrap-around service to children, adults, men, and women – including obstetrical and procedural care

Develop programs to improve the health of our patients with chronic illnesses – not only for those who come to clinic, but for all those under our care

Collaborate with other sectors in the community – such as health departments, schools, businesses, local government, and community organizations – to improve the health and well being of the entire community

Ensure that gains in health and well being occur for all, i.e., work to reduce or eliminate health inequities